Thursday, 13 November 2014

Every year about 0.76 million neonatal
deaths (death within one month of the birth) occur in India, which accounts for
28 percent of such death in the world, the greatest for any country. About
two-thirds of infant deaths and half of under-five child deaths are during the
neonatal period. India’s Neonatal
Mortality Rate (NMR) stands at 29 deaths per 1000 live birth, and the states at
high risk include Madhya Pradesh (39), Odhisa (39), Uttar Pradesh (37),
Rajasthan (35) and Chhattisgarh (31).
Though the Neonatal Mortality Rate (NMR) has declined from 52 per 1000
live births in 1990 to 29 per 1000 live births in 2012 (SRS 2012) the declining
rate has been very slow as compared to many other developing countries and
emerging economic states.

A latest report ‘State of India’s
Newborn 2014’ released by Public Health Foundation of India (PHFI) reveals the
health disparities among newborns of various communities in India. According to
the report, health outcomes are shaped not just by biological factors but also
by the social, economic, and cultural environment. Social hierarchies and
inequitable distribution of resources produce significant inequalities in the health
and well being of people.

Considering the health inequality and
social inequality interface, the poorest and most disadvantaged have a higher
risk for diseases. This includes the urban and rural poor, female children,
specially-abled persons, and traditionally marginalized and excluded
communities like Scheduled Tribes (STs), Scheduled Castes (SCs), and ethnic and
religious minorities. They also have a higher probability of being excluded
from the health services. The PHFI report states that the newborn in these
populations are expected to be the most vulnerable to morbidity and mortality. It
is evident from the empirical data on Indian neonatal and child mortality that
mortality is high among children of these socially disadvantaged and
economically deprived communities. The report by Public Health Foundation of
India has also emphasized on identifying such communities. The report says that
doing this will help in identifying entry points for action and setting
priorities for long-term improvement in neonatal survival.

High Risk Communities

High Risk Communities

Status of Neonatal Deaths

Rural Population

In rural
areas, neonates are at two times more risk of dying, as compared to their
urban counterparts. Data has recorded Neonatal Mortality Rate as high as 33
deaths per 1000 live birth in rural India as compared to 16 for urban areas.

Source:
SRS

Women

As children get older, probability of
female mortality becomes higher than the males. Females have 36 percent
higher mortality than males in the post neonatal period, but a 61 percent
higher mortality than males at age 1-4 years.

Source:
NFHS-3

Dalits and Adivasis

Child born in
a SC family has 13 per cent higher risk of dying in the neonatal period and
18 percent higher risk of dying in the post-neonatal period, as compared to
others. Similarly, a child born in a ST family has 19 per cent higher risk of
dying in the neonatal period and 54 percent risk of dying in the post
neonatal period.

Source:
UNICEF

Educationally Disadvantage Section

Children born to a mother with at
least eight years of schooling have 32 percent lesser chance of dying in
neonatal period and 52 per cent lesser chances in the postnatal period, as
compared to illiterate mothers.

Source:
UNICEF

Newborn
Care Practices among High-risk Communities

Given the diversity of India, each
community and region have their own local newborn care practices. Most of these
practices are strong and legitimate, since they originate from local culture,
environment and religion. Some of them are also based on traditional medical
knowledge of the community regarding pregnancy and neonatal care. Traditional
Birth Attendants (TBAs) are the key stakeholders in practicing and delivering
traditional neonatal for the disadvantaged population in villages, slums,
tribal areas etc. Various studies on this issue have identified many practices
that are healthy for the survival and growth of the newborn. However, studies
also identify a number of hazardous practices that leads to many prevalent
causes of neonatal death such as sepsis, pneumonia, birth asphyxia, injuries,
tetanus and diarrhea. The lack of institutional care system and prevalence of
such harmful neonatal care practices are correlated to the higher concentration
of neonatal death in villages, slums and traditional communities. Some of these
practices are described here briefly to understand their impact.

Harmful Local
Neonatal Care Practices

Health Consequences

Home Delivery by Untrained Individual

More than one
third of deliveries in the rural areas are conducted outside health
institutions. One in every four deliveries is conducted by untrained
individual/person in the villages.

Common
practices in slums and rural areas identified by number of studies reveals
that most of the newborn were given a bath immediately after birth.

Bathing immediately after birth causes
hypothermia and may lead to death

Delay in Breastfeeding

According to
the latest SRS data, during 2012-13 as high as 3.72 million newborns in India
were not breastfed within one hour of the birth

The delay in breastfeeding and feeding
baby with any liquid and solid food other than mother’s milk before the age
of six month is a harmful practice for health and survival of the newborn.

Asphysia Care

To clean the
airway of secretion, the newborn needs to be held upside down and the back
slapped immediately after birth. Many studies found that there is a lack of
knowledge about asphyxia in communities across the country and also amongst
traditional birth attendants.

Asphyxia is one of the major causes of
the neonatal death in India. Common community practices such as holding the
baby upside down and patting or massaging it, blowing in the ears, sprinkling
and dipping it in water and making loud noises are harmful for the newborn

Postpartum Hygiene

Umbilical
cord care is a big issue in villages, tribal areas and in the slums.

Cord cutting and tying practices in
rural India is one among high risk factors for neonatal infections. The blade
is commonly used to cut off the umbilical cord in rural and geographically
difficult areas but following the steps of clean cord care remain a problem.
Most people lack knowledge about sterilization of the blade and after care.

Policy
Responses and Way Forward

The entire cycle of reproduction and
local cultural practices are intertwining. There are number of good neonatal
care practices but we have also witnessed a number of harmful practices that
fuel mortality of newborns. It shows us that the issue is not just medical but also
has social dimensions. Indian Maternal and Child health policies have always
addressed social aspect in various ways. In the last decade, National Rural
Health Mission promoted community level interventions through ASHAs. However,
TBAs remain the main source for delivering both good and bad community
practices. The Indian policies never took TBAs seriously to involve them in
health system other than providing them some skill trainings. There were no
serious efforts to exchange knowledge between TBAs and modern medical
professionals. Health system needs to accommodate TBAs and consider their
community influence, traditional knowledge and skills along with knowledge gap to
promote better neonatal care in the country.

Tuesday, 4 November 2014

“Hundreds
of thousands of impoverished "low caste" Indians are being forced to
clean human excreta from dry toilets and open drains, despite a ban on the
discriminatory and undignified practice”, reports Human Rights Watch (HRW) in
its recent publication in August 2014. It is a shameful truth that reflects the
discrimination practised by society and the state towards one of the most vulnerable
sections of the population, the Dalits.

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Manual Scavenging is not only dehumanising but also dangerous.According to the Tata Institute
of Social Sciences,
80 per cent of the manual scavengers die before they turn 60 because of health
problems and accidents. In the last decade, 98 manual scavengers have died in
Gujarat. This figure was gathered by Safai Kamdar Vikas Nigam, in reply to an
RTI query and was published by the Times Of India in April 2014.

Despite
legislations prohibiting employment of manual scavengers and demolition of dry
toilets, the 'Houselisting and Housing Census 2011' data in March, 2012 shows a
bleak picture. Its estimation of insanitary
ordry latrines in the country is
close to 26 lakhs. Though there is no credible data on the exact count of manual
scavengers in the country, various surveys and sources have suggested that
there are approximately 11 lakhs manual
scavengers in India.

Legislations
banning the practice alone cannot change the social realities. There are number
of legislations to eliminate manual scavenging like The Civil Rights Act, 1955; the Construction of Dry Latrines and
Employment of Manual Scavengers (Prohibition) Act, 1993 and the recently enacted Prohibition of
Employment as Manual Scavengers and their Rehabilitation Act, 2013. However, the
twin evils of insanitary latrines and manual scavenging persist.

Our
society has to challenge and break free from the internalised caste hierarchy,
empower the minds of the manual scavengers and change the attitude of the state.

Attitude of the society

Manual
scavenging is a manifestation of the rigid caste system in India. Manual
scavengers belong to one of the Dalit sub-castes and are considered lowest in
the caste hierarchy. The society, time and again has treated Dalits as
untouchables and reserved the humiliating job of cleaning excreta only for them
thus reinforcing the idea of untouchability based on occupation. A child born into
a family of manual scavengers is denied the basic rights guaranteed under the
constitution. Manual scavenging as an occupation is passed on from one
generation to another.

In the rare occasion when a manual scavenger
challenges the social structure and his position in it; s/he is threatened by members
of higher castes, and ostracized to the extent that s/he is denied food entry
to communal land to feed their livestock, and other facilities necessary for his
survival. The community in which the manual scavenger lives does not allow them
to break free from their caste based roles.

Lack of political will of the State

Government institutions like municipal corporations,
village councils, railways and defence are the largest violators of the law and
perpetuate the problem by continuing to recruit manual scavengers and failing to
demolish dry toilets.

Indian Railways

Approximately 43,000 railway coaches are engaged in the
passenger service, and there are about 1, 72,000 insanitary toilets which
discharge the human excreta on the railway tracks that require the services of
manual scavengers. Intrigued, the
high court ordered an inspection of bio-toilets led by a team of senior
advocates P S Narasimha and Rajiv Nanda. In their status report to the court,
the advocates described work on bio-toilet installation as being extremely slow
and criticised the Ministry of Railway’s timid target of installing only 500
bio-toilets.

Municipal Corporations

A recent survey report by Manav Garima, a community
based organisation fighting against dry toilets and practice of manual scavenging
have brought to light the existence of dysfunctional toilets under the aegis of
Ahmedabad Municipal Corporation (AMC). Located in slums, these toilets do not
have proper sewerage system, water facility etc. Also, not every household has a separate toilet.
People are forced to defecate in the open. The survey which looked at few
sample areas found out that there were 126 areas where manual scavenging was practised
and there were 188 dry latrines. To make the situation worse, AMC built 30 new
dry toilets in the Nagorivad area of Ahmedabad.

A survey conducted in a few villages of Dhule in
Maharashtra, by the Rashtriya Garima Abhiyan showed that 162 women and 90 men
were hired by panchayats and municipal corporations to manually clean toilets
and open defecation areas.

Challenges faced by people and breaking the silence

People who continue cleaning human excreta do it involuntarily
under great social pressure, poverty, illiteracy and often because of the extreme atrocities they experience when
they seek alternative job opportunities.

As
reported in the Human Rights Watch publication, the manual scavengers face
resistance not only from the members of higher castes but often from local
officials like Pradhans who refuse to give manual scavengers any in

formation or
assistance in getting a job card. As a result, manual scavengers are deprived
of work opportunities provided by MNREGA.

The
fear of demanding a new life and accepting the humiliation as fate is the
greatest challenge. There are many schemes and legislations to provide education,
alternative job opportunities, trainings to manual scavengers, but these
benefits and opportunities alone cannot change their situation unless every
single manual scavenger refuses to clean other’s excreta. Until then, when a
manuals scavenger denies cleaning the dirt, there is another manual scavenger
ready to do his work. Hence, it is
crucial to make manual scavengers aware that such dehumanising work is illegal and
by mobilising them their voice can be made to be heard not as an individual but
as a group.

Role of Social Movements towards defending the right’s
of manual scavengers

In contrast to constitutional safeguards, some
civil society movements have been able to bring to the forefront the massive
discrimination faced by manual scavengers in India.

Safai Karamchari Andolan

Safai Karmachari Andolan (SKA) is a national
movement working towards eradicating manual scavenging, by organising and
mobilising the community around the issues of dignity and rights, accompanied
by strategic advocacy and legal interventions. SKA’s efforts helped to uncover
the fact that government
departments including Railways, Defence, Judiciary and Education are violators
of the Manual Scavenging Prohibition Act. A Public Interest Litigation (PIL) was filed
in the Supreme Court by SKA and 18
other civil society organisations in 2003. As a result, the Supreme Court gave strict orders to all
the states and central ministries to address the issue of manual scavenging. In
2010, for the first time 23 hearings were conducted in the state of Haryana and the act
was enforced and 16 members were taken into custody for violating the law and
employing manual scavengers.

Rashtriya Garima Abhiyan

Launched by Jan Sahas
Development Society, the “Rashtriya Garima Abhiyan” is a national campaign for dignity
and elimination of manual scavenging. The Abhiyan has liberated 11,000 manual
scavengers in Madhya Pradesh. By organising sanghatans
or community-based organisations, it has mobilised manual scavengers and
empowered them to oppose all kinds of discrimination. Liberated and empowered,
manual scavengers have taken the lead in putting an end to this practice. The
campaign has been taken to other villages and states. In December 2012, the Rashtriya
Garima Abhiyan, also organised a two-month long march ‘The Maila Mukti Yatra’ across
18 Indian states that liberated thousands of manual scavengers.

Similar success
stories have been showcased by other national and local level movements which have
successfully spread awareness and empowered manual scavengers and helped them
fight against their own fears and challenge the rigid social structure and government
institutions that are responsible for depriving them of their rights to live in
dignity.

Journey towards changing mindsets

Manual
scavenging is “shame of the nation” said Mahatma Gandhi. The fight to end manual scavenging is more
than one individual’s struggle; it is a struggle of the nation. Social
movements have shown positive change by bringing people together. For a change
to happen at a large scale, it is important for all the segments of the society,
including civil society organisations and the state, to join hands and fight
against the violation of human dignity.

Legislations
and schemes prohibiting manual scavenging, as modernising India’s sanitation, are important. But for effective implementation
of these, mindsets of people, society and state needs to undergo change. Synergised
efforts towards challenging the caste structure, changing the mindsets of
people involved in scavenging and people employing them as scavengers can make
a significant positive difference.